Friday, January 4, 2013

New Psychiatry CPT Codes: Don't Panic

If you're a psychiatrist (or psychiatric RNCS) in the US reading this, you are almost certainly aware that all of our billing codes changed on Jan 1, 2013. If you are like most of the psychiatrists I know—at least in private practice—you are at least somewhat freaked out by this. If so, keep reading. If not—for example, if you're not a psychiatrist in the US—stop reading this immediately and go do something more interesting, like... well, like just about anything other than memorizing a phone book. (There used to be things called phone books... never mind.)

I made up a one-sheet reference, which I think can help with the codes. There are links to it at the bottom.

Here are some links that I've used for reference, trying to understand this. The "little" APA has a helpful page with many links, most of which are pdfs available to both members and non-members, at http://www.psychiatry.org/cptcodingchanges. The "Overview of the 2013 Changes " will get you started; the last two pages, which are also included separately as "E/M Summary Guide: Coding by Key Components," were the single most helpful reference for the complexity-based E/M codes, which you will quickly realize are the only really challenging issue here. I also found the "Patient Examples Outpatient E/M Visits" helpful. And finally, the comprehensive reference seems to be "Evaluation and Management Services Guide from CMS ." (Note that while the APA site says that it "does not replace content found in the 1997 Documentation Guidelines for Evaluation and Management Services, abridged version for psychiatrists [listed above]," it seems to contain the full 1997 guidelines as an appendix, so I'm not exactly certain what they mean...)

My advice, at least at the beginning, is to avoid the E/M codes for initial visits, and use the generic initial evaluation code, which replaces 90801. Some of the E/M codes for initial visits will probably end up reimbursing better than the generic code. Again, my advice: save that for later.

Unfortunately you need to use the complexity-based E/M codes if you are doing psychotherapy and medications together (e.g., the old 90807), which you now need to code with a complexity-based E/M code and a psychotherapy "add-on." I suspect I will mostly end up using 99212 and 99213, but some colleagues have pointed out that 99214 is workable, especially for those doing geriatric psychiatry.

So, with the exception of the initial-visit E/M codes, I boiled it down into a one-page reference, which anyone is free to redistribute as far and wide as they link. Links are at the bottom of this page. When you click on that link, if the file opens in a browser window rather than downloading, you should just be able to go to "Save" in your browser's File menu to save the pdf or .doc file on your hard drive. I am not charging for it (though in the spirit of "shareware" I'm happy to accept donations from anyone who feels so moved, see the "Support" button to the right). I'm making it available as "open source" material under a Creative Commons license (more info at the bottom), which means that you could change it and redistribute it as long as you do so in compliance with the license (meaning that if you change it and distribute it to others you attribute the original). The license actually does not rule out commercial use.

Feedback and comments are welcome! (I am aware, by the way, that I made one simplification: it is possible to hit the criteria on medical decision-making based on problem and data points alone, but I can't really ever see that happening without also hitting the risk criteria).

And of course, the obligatory disclaimer. I am not an expert in this stuff, this is simply my best understanding of it. It is quite possible that there are errors in the reference, and if you find any, please tell me. But you are, as always, responsible for your own coding and documentation and I can't assume any responsibility for any problems that come up for anyone but me.

I've also made a form for taking notes in session (or for learning the system between sessions) which should make documentation and coding easier. More information at tiny.cc/emform.

I'll try to keep the "current" links up to date so you don't have to chase around to find the current version; on the other hand, if you don't like the changes you can stick with the original. Each intermediate version should have a blog entry so that it can be found as well.

15 comments:

It is somewhat helpful. But for some reason no one anywhere has given an example.Can E/M codes be use for psychodynamic issues, or only for medical issues.Can I use an E/M code for anxious preoccupied attachment, alcoholism, depression, hypomania.It is rather frustrating. How do psychiatrists doing psychotherapy use these new codes.I understand I have to use an E/M code with an add on psychotherapy code. What I need is a clinical example of how I would use the E/M codes as a psychiatrist doing psychotherapy/med management weekly appointments.

Here's my understanding:1. Yes, you can definitely use E/M codes for psychiatric issues: alcoholism, depression, etc.2. The "Patient Examples Outpatient E/M" link above is quite helpful for the E/M code examples, but it doesn't include an add-on example. However, it's a good place to start for the E/M code.3. For the psychotherapy add-on, you would have to document the amount of time spent on psychotherapy, and make sure that the note contains whatever documentation you would need for the psychotherapy code (some of which may already be there from the E/M code).4. Alternatively, it's possible to skip the psychotherapy add-on and just use a time-based E/M code, but presumably the reimbursement isn't as good.

Please define what you mean by elements, bullets and data points.Why would it be important for me to do a ROS as a psychiatrist that does med management and psychotherapy.How do I put psychodynamic treatment into an E/M code.HELPI think it would be best to give an clinical example of a patient that comes to a psychiatrist for both meds and psychotherapy and how to approach the CPT codes and the documentation.Any idea of anywhere I can find this.

OK, so I'm serious about the "Don't Panic" thing. So, assuming you were able to download the pdf from the link that says "I will try to keep this a link to the current pdf":1. "Elements" are listed in the first column under "History" right after where it says "Elements:"2. "Bullets" are listed in the second column, under "Exam". Each one is preceded by a bullet (black circle).3. "Data Points" are listed in the third column under "Medical Decision-Making". Each data item is followed by a bold-faced digit, which is the number of "points."

These are spelled out with more detail, clarity, and precision on the EM encounter form on my other post... even if you don't want to use the form (which I actually don't), looking it over should help clarify some of these questions.

Also, please see the reply to the previous comment. The APA E/M examples are very helpful.

In terms of the ROS: the psychiatric ROS will cover things that aren't in the "HPI". For example if your HPI elements are about the severity of dysphoria, your ROS might include sleep, appetite, anxiety... which are all things that it is fairly reasonable to ask about. If you want to hit the criteria for 99214, you would need to include two other systems. There are many relevant examples on the EM encounter forms (e.g. sexual side-effects would count under GU ROS). I don't think there is a requirement to even label it as "GU," it just needs to be there. Overall, I don't think that this is really asking for anything beyond what we already do.

There are not enough people in the country to be going over every note we write with a fine-toothed comb, but some kind of good-faith effort to meet these guidelines seems like what's called for.

Just so you know:A psychiatrist doing psychotherapy would get reimbursed the following rates with the new codesI used to get 200 to 300 dollars for a 90807Now I will get 45 dollars for a 99212 and 56 dollars for an add on 90836 so about 100 dollars. I went to school for 15 years and did extra training in psychodynamic psychotherapy and Dialectical Behavioral Therapy. Why is my training being so minimized and undervalued.

Does anyone know of a computer electronic medical record that is designed with the documentation and coding required for these new changes?It is far too complex for any psychiatrist in private practice to do manually.Is there a template available in an electronic medical record that documents and codes automatically?If not it should be designed don't you think

I'm sure that people are doing templates for EMR systems, but I disagree that this is too complex to do manually. It takes some time to absorb it, but it is not really that different from what we have been doing (or should have been doing). It's just a matter of documenting that in a way that is roughly compatible with the standards. My recommendation would be to absorb the 99213 standards and then, if you want to get the higher 99214 reimbursement, see what you would have to do in order to meet that bar.

I think the outcome of all of this is that psychiatrists in private practice will stop taking insurance completely, including patients using their insurance for out of network providers. This is going drastically limit access to psychiatric/psychotherapy care.It is astonishing and outrageous how these new codes will limit access to care for millions of patients that need it. Psychiatry in private practice will truly become a luxury for the rich only.

I agree wholeheartedly with the "Anonymous" comment above (2/24/13). I am a patient that found a wonderful psychiatrist for psychotherapy. I can no longer see him, because he does not do insurance billing, nor will he familiarize himself with the new codes. In fact, I was not even aware that there was a new billing code system at the beginning of 2013. It is now up to me to tell him how to code for my 13 visits, for which I paid cash. This is why I came to this site, in hopes of being able to understand well enough to recommend how he should fill out the claim form, in hopes of getting SOME reimbursement! I am a high-functioning patient and am having difficulty in sorting this out, so I can only imagine how many patients would just give up and not get any care at all. It is pathetic what this new coding system is doing to psychiatric health care in the nation. I was starting to see real improvement and had to stop getting the care that I need.

About Me

I am a psychiatrist in private practice in Belmont, MA, USA, and a Lecturer (Part-Time) in Psychiatry at Harvard Medical School. The main focus of my practice, teaching, and writing is Intensive Short Term Dynamic Psychotherapy (ISTDP).